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i <br /> i <br /> APPLICATION FOR PERMIT <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.TON AVE., STOCKTON, CA DECEIVED <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 9 YEAR FROM DATE ISSUED Avg 2p\ <br /> (Complete in Triplicate) --_ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thei ijcation is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules n W(g San Joaquin <br /> Local Health District. <br /> Job Address City <br /> Lot Size PM <br /> Address Phone <br /> Owner's Name <br /> CO <br /> Contractor - Address Vrdr License No.&1�f3f3 Phone, <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER [� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom 7' ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Fl Public ❑ Other ❑ Defta. Depth of Grout Seal Type of Grout _ <br /> I Irrigation - Approx. Depth I I Eastern g Surface Seal Installed by - <br /> • �v@�✓� <br /> Repair Work Done «�» Type of Pump,-�R-G' H. 4Work Done t,t� <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material I Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feetA <br /> Installation will serve: Residence_i,Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: w Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT''P. -* Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ' R <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED LI Distance to nearest: Welt Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size _ Number <br /> SUMPS 0 _Distance to nearest: _ Well Foundation Property Line s <br /> DISPOSAL PONDS ❑ r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> t rules and regulations of the San Joaquin Local Health Di§trict. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which,this permit is issued, I shall t <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> i certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." ' <br /> The applicant must all all required inspections. Complete drawing on r verse side. <br /> T <br /> IV Signed X �' � Date: <br /> Title: - - <br /> ® %" R DEPARTMENT USE ONLY <br /> r Application Accepted by Data -Area <br /> F Pit or Grout Inspection by Date Final Inspection b Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMITNO. <br /> INFO <br /> i.EH1t4-28 13-24{REV. <br /> EH 1/95) � Z—S; �JO / <br /> p <br />